Atul Gawande on the electronic medical record

Atul Gawande has a piece in the New Yorker titled Why Doctors Hate their Computers. The title is deceptive. In the first place doctors don’t hate computers (I’ve never met one who did, have you?). In the body of the paper Gawande doesn’t even seem to attempt to make that case. He does point out how doctors hated the way in which they were forced to adopt health information technology and the culture that went alongside. But, though he talks around it (and he talks a lot around it) he fails to answer the question of why. Is there something wrong with computers themselves in the current state of development? Is it the way policymakers and administrators have forced the implementation? Or is it that docs just need an attitude adjustment? He implies a little of each. Overall the article is incoherent.

Gawande has thrown together a mishmash of anecdotes, unreferenced claims and quotes from supposed experts. And the qualifications of these experts? Well, consider this one:

Gregg Meyer sympathizes, but he isn’t sorry. As the chief clinical officer at Partners HealthCare, Meyer supervised the software upgrade. An internist in his fifties, he has the commanding air, upright posture, and crewcut one might expect from a man who spent half his career as a military officer.

Hmmm. A commanding air, an upright posture and a crewcut. I think I’m afraid of this guy. He seems to think doctors have too much autonomy and a bad attitude to boot. He says:

“But we think of this as a system for us and it’s not,” he said. “It is for the patients.” 

Emphasis his.

Meyer just gave himself away. He’s operating on the idea that the interests of doctors are opposed to the interests of patients. It’s an ethical question worth pondering but not a great starting premise. Gawande seems to accept it uncritically. A little further on Gawande says of Meyer, also uncritically:

Gregg Meyer is understandably delighted to have the electronic levers to influence the tens of thousands of clinicians under his purview. He had spent much of his career seeing his hospitals blighted by unsafe practices that, in the paper-based world, he could do little about.

Evidence based medicine, particularly its third pillar (the importance of the expertise of the individual clinician) opposes such a top down approach. Does Gawande see anything wrong with Meyer’s line of thinking? If he does he doesn’t say so.

It’s style over substance:

Jessica Jacobs, a longtime office assistant in my practice—mid-forties, dedicated, with a smoker’s raspy voice—

As if that’s supposed to be a convincer in some way. But what does it mean, exactly? That she’s got savvy? That her dedication to her work has taken its toll? It’s left to our imagination.

Gawande fails to even come close to making the case that doctors hate computers, let alone answer the question of why, but he does point out some of the negative consequences of the EMR. Maybe this is progress, because it would have been nearly forbidden speech about a decade ago.

The EMR mess and its horrible consequences

What practicing docs knew all along.

The adverse effects of CPOE on ER throughput

Discussion at SGEM and primary source.

Pitfalls in ICU management

This article in Today's Hospitalist, drawn from recent talks at the UCSF hospitalist conference, has a lot of pearls. Most of the admonitions are about avoiding knee jerk care.

The real gem comes in her discussion of the importance of de-escalation of IV fluids:

“Multiple studies have replicated that, even in sepsis,” Dr. Santhosh noted. “After initial resuscitation with early goal-directed therapy, you want a maintenance or stabilization phase and then de-escalation.” That could mean active diuresis in patients to attain a negative fluid balance once they’re off pressors.

And while it can be a challenge to find the maintenance fluids in your EHR to discontinue them…

That’s right. She said, in effect, that the EHR interferes with the clinician’s ability to discontinue potentially harmful IV fluids. The statement rings true and concerns one of those key provisions of meaningful use: CPOE. Meaningful to patients for sure if it interferes with their care with the potential for harm.

Apps you can use

I found some good ones I had not heard about in this list.

Machine learning in medicine

This JAMA Viewpoint article highlights the weakness of reliance of computer decision support for diagnostics.

First glance heuristics

An important part of the physical exam. But the EMR often distracts us.

EMRs slow physicians down and distract from real clinical care

Tell me something I didn’t know.

Computerized physician order entry: a negative factor in physician productivity and morale

From a new study:

Abstract:

Objectives: To examine the impact of clerical support personnel for physician order entry on physician satisfaction, productivity, timeliness with electronic health record (EHR) documentation, and physician attitudes.

Methods: All seven part-time physicians at an academic general internal medicine practice were included in this quasi-experimental (single group, pre- and postintervention) mixed-methods study. One full-time clerical support staff member was trained and hired to enter physician orders in the EHR and conduct previsit planning. Physician satisfaction, productivity, timeliness with EHR documentation, and physician attitudes toward the intervention were measured.

Results: Four months after the intervention, physicians reported improvements in overall quality of life (good quality, 71%–100%), personal balance (43%–71%), and burnout (weekly, 43%–14%; callousness, 14%–0%). Matched for quarter, productivity increased: work relative value unit (wRVU) per session increased by 20.5% (before, April–June 2014; after, April–June 2015; range −9.2% to 27.5%). Physicians reported feeling more supported, more focused on patient care, and less stressed and fatigued after the intervention.

Conclusions: This study supports the use of physician order entry clerical personnel as a simple, cost-effective intervention to improve the work lives of primary care physicians.

This would represent going back to what we had before meaningful use, not a new intervention.

Low value systems update: CPOE based insulin order sets didn’t help with glycemic control

Maybe less is more here.

Best practice advisories in the EMR

No evidence that they improve real quality and they may cause harm.

Where will artificial intelligence take us?

According to Bob Wachter it’ll be well on its way to taking over the diagnostic role of the clinician, and in as little as 5 years:

In about 5 years, Dr Wachter predicted, a physician will be able to dictate a patient note into a computer, and the computer — using artificial intelligence — will review the chart and the literature and offer a likely diagnosis or care path.

I don’t believe it. The simplest and most formulaic attempt at this, computer interpretation of ECGs, has gotten us nowhere in over 40 years.

But no doubt there will be efforts to implement this sort of thing, thus furthering the epidemic of misdiagnosis.

Let doctors be doctors

Back when the EMR dogma was being shoved down our throats we were intimidated against speaking out (it sort of reminds me of the fifth vital sign movement). That is changing.

Medication safety alerts: why they don't work

Here's a secondary analysis of 26 papers.

Medication alerts generated by the EMR are rarely heeded

---according to this study.

Via Hospital Medicine Virtual Journal Club.

Adopting the EMR: trading one set of problems for another

A recent review on the impact of the electronic medical record reminds of a sobering fact: that despite years of wishful thinking, research findings have been disappointing. It would be generous to say they have been mixed because by and large the positive findings have been confined to soft and non validated surrogate metrics. As suggested in the title of this post the EMR seems to create as many problems as it addresses. From the review:

Electronic provider order entry processes may lower the chance for errors based on the legibility or misplacement of paper orders.2 Other types of errors, for example, automatic renewals, cancellations of orders, and inappropriate dosing of medications, may actually increase with the EHR.3 Cut-and-paste options also increase the risk for errors in documentation.4 Computer systems are vulnerable to malfunctioning hardware and software and may run slowly. In addition, access could be difficult in a busy healthcare setting.5...

The primary care physician evaluating the multitude and diverse problems of medically complex older adult patients is especially vulnerable to the inefficiencies of EHR utilization. Check-box features and the automatic importation of laboratory values and medication profiles can lead to “note bloat” and boilerplate documentation that can obscure important clinical findings from the reader.6,7

The boilerplate “note bloat” referenced above is the EMR's answer to the doctor's handwriting, trading one form of illegibility for another.

The EMR is but one of several “systems” (e.g. the hospitalist model, rapid response teams, performance measures) which, though touted as solutions to various health care problems, have one by one been disappointing when subjected to scientific scrutiny.

EMR frustrations

This post from FIRM is another reminder to me that doctors are getting more outspoken in their negativity about the EMR. I don't know if that's because they're just now realizing it isn't living up to its promise or if doctors have become emboldened. Just a few years ago it was politically incorrect to question the value of the EMR.

A recent systematic review of health information technology

This updated systematic review on the effects of HIT recently appeared in the Annals of Internal Medicine. The focus was on meaningful use aspects, particularly clinical decision support and CPOE. A few studies looked at the effect of patients' access to their own EMRs. The results were mixed but tended to be positive. The vast majority of reports were on processes or very low level surrogates, with very few studies looking at meaningful clinical outcomes. Among those, however, were a couple of reports suggesting reduced mortality attributable to HIT.

How EMRs, core measures and other “system improvements” degrade patient care

There's a great essay on this subject at Medpage Today. I would just add that it's not so much the computer that degrades care as it is the culture we've built around it.

George Lundberg: the EMR is a mess

Still, after all these years.